Dipti Itchhaporia, MD, FACC, FESCImmediate Past Trustee, American College of Cardiology

Director of Disease Management, Hoag HospitalRobert and Georgia Roth Endowed Chair for Excellence in

Cardiac CareJeffrey M. Carlton Heart and Vascular Institute

Assistant Clinical Professor, University of California, Irvine

Optimizing STEMI Systems of Care

I have no

disclosures

Disclosure

Time and Mortality in STEMI Patients

15.4

23.3

28.1

30.8

0

5

10

15

20

25

30

35

Mortality, %

0 to 60 min 61 to 120

min

121 to 180

min

181 to 360

min

Terkelsen CJ JAMA 2010;304:763-771

Longer D2B – higher mortality

Shorter time from door-to-balloon (PCI) leads to lower risk of mortality

Time from Symptom Onset to Treatment Predicts 1-year Mortality after Primary PCI

De Luca et al. Circulation 2004;109:1223-1225

The relative risk of 1-year mortality increases by

7.5% for each 30-minute delay

Do whatever it takes to reduce time from symptom onset to ER arrival and time from ER arrival to PCI!

Public awareness of MI Sx

CAD centers of excellence with

lower DBTs and excellent outcomes

Regional coordination

Ambulance ECG telemetry

Ambulance/ER CCL activation

ICs sleep in hospital

Continual QI

Mehran, Roxana

Barriers to Timely Reperfusion• The patient

• Failure to promptly recognize symptoms• Hesitation to seek medical attention

• Time to transport• Mandated delivery to the closest hospital, regardless of PCI

capabilities• Long transport in rural areas

• Decision process on arrival• Clot-busting drugs vs. PCI• Off hours• Transfer to PCI facility

• Time to implement treatment– Procedural factors• Team assembly

6

The Reality of Today’s Patients• Not all STEMI patients call 9-1-1

• 50% of STEMI patients present to their local emergency department (ED)

• “Walk-in” patients • Rapid ECG

– CODE 10 Established – ECG in under 10 minutes from time of arrival (DOOR TIME)

– Operational Considerations• CODE 10 called overhead in ED• multiple available ECG machines • process in place to mobilize ECG machine and tech• training/ competency of Emergency Care Techs to perform

ECG• high priority of ED MD to read ECG

7

The Ideal Patient & System• Patients and the public:

• Recognize the symptoms of STEMI • Realize the importance of:

• Activating emergency medical services (EMS) via 9-1-1 promptly

• Getting treatment quickly

• The ideal system:• Promotes education efforts for the

Emergency Medical System, the Emergency department personnel, cath lab staff, physicians and the patients.

• Provides coordinated and patient-centered care

8

Transport: Patient to ED by Ambulance

• Coordination with Emergency Medical System

• 12 Lead ECG performed in field

– Appropriate ECG machines on ambulance capable of transmitting clean tracing

– Training/ competency of EMT to perform ECG

• EMS transmits to Base Hospital, BH contacts Cardiovascular Receiving Center (CVRC)

– Our institution is both a BH and CVRC

• Radio call to ED

– Notifies ED MD, ED RN, Activates CATH LAB –simultaneously

– ED MD contacts ED CALL PANEL On Call Interventional Cardiologist

The Ideal Emergency Medical System (EMS)• In an ideal system:

• Ambulances are equipped with 12-lead ECG machines• EMS providers are trained to:

• Use and transmit 12-lead ECGs• Care for STEMI patients• Provide feedback on performance and compliance

with guidelines• Standardized point-of-entry (POE) protocols define patient

transport rules• When there is STEMI, the cath lab is activated promptly• Patients transported to a STEMI-referral hospital remain

on the stretcher with EMS present pending a transport decision

• When “walk-in” patients present to a STEMI-referral hospital and require primary PCI, activation of EMS occurs

• Hospitals close the communication gap with EMS

10

PROCESS:STEMI Presentation: EMS v. Walk-In

EMS

• STEMI Recognition by EMS Pre-Hospital Prior to “DOOR”

– Education & Collaboration with EMS for timely and accurate 12 Lead ECG

• Pre-hospital activation of ED, CCU & CCL Team CODE STEMI

– 30 minute arrival time

• ED MD interprets ECG upon pt arrival, repeats if necessary.

11

Walk-In

• STEMI Recognition upon arrival of Walk–In CODE 10:

ECG within 10 min

• ED MD primary interpretation of ECG with simultaneousactivation of IC and CCL TEAM

STEMI Treatment

GOAL: Achieve D2B < 90 minutes <60 minutes• Key Criteria

– Early activation – Door to Data/ECG < 10 min– Door to Decision < 15 min– Door to Cardiac Cath Lab (CCL) < 30 minutes– CCL door to Ready for Stick < 10 min– CCL door to BLN < 45 min

12

13

Early Data

14

Dedicated Mobile Phones in EDFor STEMI Notification

• Programmed with IC Cell Numbers

• ED MD speaks directly with IC • Program IC’s cell phones with

ED Cell identifier as “STEMI”

STEMI

STE

MI

Next StepsTracking Progress

Create evaluation mechanism to track progress and outcomes- and give feedback

16

Time

________

________

"Door to Data"

________ National Goal = 10 minutes

Hoag Goal < 10 minutes

________ "Door to Decision"

________ Hoag Goal < 15 minutes

Interventional Cardiologist: __________________

________

________

________ ED arrival to CVL arrival

Hoag Goal = < 40 minutes

"ED to lab"

________ Hoag Goal < 5 minutes

________ "CCL door to ready"

Hoag Goal < 10 minutes

________ "Lab ready to Stick Time"

Hoag Goal = 0 minutes

Artery Open (time of 1st balloon inflation) ________ "CCL arrival to balloon"

Culprit artery: ________________________ Hoag Goal = < 45 minutes

________

________

Goal D2B = < 90 minutes

Goal E2B = < 90 minutes

Primary PCI Data Collection FormThis is NOT a Permanent Part of the Patient's Record

Benchmark Time or Goal

REFERENCE

Date & time patient first arrives to Hoag:

ED calls Interventional Cardiologist

ED Physician: ____________________________

Please copy and attach:

1.) EMS field ECG,

2.) EMS run Sheet,

3.) ECG(s) from ED,

4.) ED triage sheet

Immediate post-procedure pt disposition &/or location:

_____________________________

Patient arrives in CCL from ED

(Please document if room not available.)

Local

Total ED door to balloon (D2B) time =

Patient ready - prepped & draped

Total EMS to balloon (E2B) time =

Hoag Goal = < 30 minutes

following notification

Initial ECG obtained: EMS____ Hoag______

STEMI? Yes______ No______

If EMS ECG, was the field interpretation confirmed?

Yes _____ No_____

Time 1st ECG obtained

Patient ready for transport to CCL:

Call Team arrival time to hospital:

Cardiologist arrival time to hospital:

ED calls Perfect Serve to activate Call Team

Data Element

"Door" ie.: Arrival to hospital

Card

iac C

ath

Lab

Resp

on

sib

ilit

y

Date AND Time ED notified of patient arrival:

Arrival by: EMS _____ BLS _____ Walk-In _____

OCS-EMS Identification (run) #:______________

Medical Record #:_________________________

Patient Age: _____ Male ____ Female_____

Em

erg

en

cy D

ep

art

men

t R

esp

on

sib

ilit

y

Hoag Goal = < 30 minutes

following notification

Primary PCI Data CollectionForm

• Initiated Dec 2010

• Completed by designated CCL RN’s

• Reviewed and reported by AMI Team Leaders

• Immediate, real-time feedback for all

Door 2 Balloon Time (in Minutes)

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Partners for Success

• Patients and care givers

• EMS providers

• Physicians, nurses and other providers

• STEM-referral (non-PCI) hospitals

• STEMI-receiving (PCI-capable) hospitals

• Health systems

• Departments of health

• EMS regulatory authority / office of EMS

• Quality improvement organizations

• State and local policymakers

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Summary- STEMI Management

Kristensen, S. D. (2018). 2017 European Heart Journal, 39, 119-177.